Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
When a Managed Care SIU Refers Your Case to the State
Federal rules require Medicaid managed care plans to refer suspected fraud to the state agency or the MFCU. Here is what triggers…
Settling a Medicaid Overpayment Before the Final Audit Report
A state Medicaid overpayment can be negotiated before the final report issues, but the settlement must address referral and exclus…
Deactivation Versus Revocation of Medicare Billing Privileges
Medicare deactivation pauses billing and leaves a path back in. Revocation ends the provider agreement and can bar reenrollment fo…
Continuous Home Care in Hospice: Medical Review Triggers
Continuous home care is hospice's most expensive level of care. Here is the hour count, staffing mix, and crisis proof Medicare re…
Amount in Controversy for Medicare ALJ Hearings and Federal Court
CMS raised the 2026 Medicare amount in controversy to $200 for an ALJ hearing and $1,960 for federal court review of a denial or o…
Personal Exposure for Owners and Ordering Physicians in a UPIC Audit
A UPIC overpayment finding against the billing entity can still reach the practice owner, a buyer, or the ordering physician's own…
CGS Administrators Medicare Audits: Part B and DME MAC Review
CGS Administrators runs Part B physician review and DME MAC review under separate rules. What a CGS records request actually means…
Minnesota DHS Surveillance and Integrity Review Audits
Minnesota DHS renamed SIRS to MPAI, but the audit authority is the same: payments can be withheld on a credible fraud allegation,…
MFCU Search Warrants and Records Seizures
When MFCU investigators execute a search warrant at a healthcare practice, Fourth Amendment limits, privilege protections, and cou…